Fulton County Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcconnellsburg, Pennsylvania.
- Location
- 214 Peach Orchard Road, Mcconnellsburg, Pennsylvania 17233
- CMS Provider Number
- 395387
- Inspections on file
- 21
- Latest survey
- April 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Fulton County Medical Center during CMS and state inspections, most recent first.
An audit by the DON found five expired medical items in the back medication room, which had not been removed as required by the third shift RN.
The facility failed to maintain the automatic sprinkler system, as two unsealed penetrations were found in the ceiling tiles of the LTC Gym, potentially affecting the system's operation in one of the smoke compartments. This deficiency was confirmed by the Facility Administrator and Plant Operations Manager.
The facility was found to have corridor door deficiencies in two smoke compartments. The doors to Room 23B in the Overly Wing and Room 10B in the Shimer Wing failed to close and latch properly, compromising their ability to resist smoke passage. These issues were confirmed by the Facility Administrator and Plant Operations Manager.
A resident with Type I diabetes in an LTC facility received incorrect insulin dosages on multiple occasions, contrary to physician orders. The facility's policy required adherence to prescribed medication dosages, but staff administered higher doses than ordered and failed to withhold insulin when necessary. The DON confirmed these errors.
Expired medical supplies were found in two medication rooms, Overly Meadows and Shimer Trails. In Overly Meadows, expired angiocatheters, a needle, and saline solution were discovered. In Shimer Trails, expired IV catheters, needles, and a syringe were found. LPNs and the Nursing Home Administrator confirmed these items should not have been in circulation.
Fulton County Medical Center failed to provide required written notices to the State Long-Term Care Ombudsman and residents' responsible parties for two emergency hospital transfers. One resident experienced severe medical symptoms, including a skin rash and bleeding, while another showed signs of infection. The facility did not document the necessary notifications, as confirmed by the DON.
A resident's care plan was not updated to reflect changes in dialysis treatment, including the removal of a hemodialysis catheter and the use of a fistula. Despite the resident's cognitive intactness and confirmation of these changes, the care plan remained outdated, as confirmed by the DON.
The facility failed to obtain necessary hospice documentation for two residents receiving hospice care. Despite agreements with the hospice provider, critical forms like the Hospice Benefit of Election were missing from the residents' records, indicating a lapse in communication and documentation.
A facility failed to follow proper infection control practices during wound care for a resident with a left arm hematoma and sepsis. An LPN did not perform hand hygiene after removing gloves and before donning new ones, and also failed to sanitize hands before repositioning the resident's pillows. The DON confirmed these actions were against the facility's hand hygiene policy.
The facility failed to maintain the automatic detergent dispensing system in the laundry area, leading to manual detergent transfer by staff. The issue persisted for three months without effective resolution, as the Environmental Service Director was aware but did not follow up on replacement parts, and the Nursing Home Administrator was unaware of the problem.
A resident in an LTC facility, who was cognitively impaired and dependent on staff, suffered a dislocated shoulder due to neglect. The resident exhibited increased behaviors and requested pain relief, with nursing notes documenting bruising and swelling on the upper arm. An investigation revealed that a nurse aide forcibly moved the resident's arm, causing the injury, which was confirmed by a witness and the Director of Nursing.
A resident with cognitive impairment suffered a dislocated shoulder due to a nurse aide's forceful handling, which was not reported immediately as required by the facility's abuse policy. The delay in reporting led to a delay in treatment, as the incident was only disclosed six days later during an investigation.
A resident with cognitive impairment and dependency on staff experienced an incident where a nurse aide forced their arm, causing pain and deformity. Despite complaints, there was no documented evidence of a comprehensive assessment by an RN on the following days, as confirmed by staff interviews.
The facility failed to store food according to professional standards, with observations revealing opened and unlabeled food items in the walk-in freezer and refrigerator. The Dietary Manager confirmed that staff should label food items with a sticker when a new container is opened and date the containers when opened.
The facility failed to develop a comprehensive care plan for a resident with a pulmonary embolism requiring long-term use of anticoagulant medications. Despite a physician's order for Apixaban, no care plan was created to address the use and risks of the medication, as confirmed by the Director of Nursing.
The facility failed to update care plans for four residents to reflect their specific care needs, including delusional thoughts, fall prevention interventions, discontinuation of CPAP, and suicidal ideation. The Director of Nursing confirmed these deficiencies.
The facility failed to assess a resident's ability to self-administer medications and did not obtain a physician's order for self-administration. An LPN left a Carafate tablet with the resident, contrary to the facility's policy requiring the nurse to stay until the medication was taken.
A facility failed to notify a physician about a resident's repeated medication refusals over three months, despite a care plan requiring such notifications. The DON confirmed the lack of documentation for these notifications.
A resident with Parkinson's disease and dementia developed a pressure ulcer due to improper brief placement. Despite identifying a red mark on the resident's thigh upon admission, the facility failed to document any preventive measures, leading to the development of a blister. The DON confirmed the lack of documented preventive actions.
The facility failed to use wheelchair footrests during the transport of two residents, leading to potential injury risks. Both an LPN and a Nurse Aide transported residents without the required footrests, contrary to the facility's policy.
The facility failed to complete annual performance evaluations for two nurse aides as required. One nurse aide, hired in April 2021, did not have an evaluation for April 2023, and another, hired in June 2022, did not have an evaluation for June 2023. The Nursing Home Administrator confirmed the absence of these evaluations.
The facility's QAPI committee failed to correct and maintain compliance with deficiencies related to notification of changes in resident conditions and annual nurse aide performance evaluations. Despite previous plans of correction, the current survey revealed repeated deficiencies in these areas.
Expired Medical Supplies Not Discarded in Medication Room
Penalty
Summary
The facility failed to discard expired medical supplies in one of two medication rooms, specifically the back medical room. During an audit conducted by the Director of Nursing, five expired items were identified in this room. The Director of Nursing confirmed in an interview that these expired items were found during her audit and acknowledged that they should have been removed by the registered nurse on the third shift. This deficiency was identified through a review of facility audits and staff interviews.
Plan Of Correction
Re-education was initiated on 7/2/2025 with registered nurses and licensed practical nurses, providing on-the-spot education for monitoring expired supplies and ensuring expiration dates are checked on supplies prior to being put into use. Education will be complete by 7/15/2025. A registered nurse meeting was completed on 7/10/2025, which included a review of on-the-spot education regarding the current process to confirm all registered nursing staff understand their role in ensuring compliance. Those not in attendance will receive a one-on-one conversation regarding on-the-spot completion and to ensure they understand their role in ensuring compliance by 7/15/2025. The Director of Nursing will continue with weekly audits of medication and supply rooms on the units to ensure no expired medical supplies are present. The Quality Assurance and Performance Improvement team is scheduled for an additional meeting on 7/11/2025 and will review the current process and the results of the audits related to expired supplies. All expired supplies have been removed from storage, returned to purchasing, and disposed of. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Automatic Sprinkler System Deficiency Due to Unsealed Ceiling Penetrations
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by an observation on April 22, 2025, at 12:25 p.m. During this observation, two unsealed penetrations were found in the ceiling tiles of the LTC Gym, specifically on the left side of the gym. This deficiency could potentially affect the operation of the automatic sprinkler system in one of the four smoke compartments. An interview with the Facility Administrator and Plant Operations Manager later confirmed the presence of this automatic sprinkler system deficiency.
Plan Of Correction
1. The facility replaced 2 ceiling tiles and corrected unsealed penetrations in the LTC gym on April 23, 2025. 2. Facility maintenance staff will complete visual inspection of ceiling tiles each quarter during their regular penetration inspections. The LTC Quarterly Penetration Inspection form was updated on 5/6/2025 to reflect documentation of the visual inspection. 3. Completion of visual inspection of ceiling tiles and documentation of such will be audited during the monthly Building and Safety meeting which is attended by Plant Operations Manager, Director of Environmental Services, FCMC Safety Officer, Nursing Home Administrator and Chief Operations Officer for twelve months.
Corridor Door Deficiencies in Smoke Compartments
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as observed during a survey on April 22, 2025. Specifically, two corridor doors in different smoke compartments were found to be deficient. At 10:58 a.m., the door to Room 23B in the Overly Wing was observed to not close and latch properly in its frame. Similarly, at 11:35 a.m., the door to Room 10B in the Shimer Wing also failed to close and latch in its frame. These deficiencies were confirmed during an interview with the Facility Administrator and Plant Operations Manager on the same day at 2:00 p.m. The inability of these doors to close and latch properly compromises their ability to resist the passage of smoke, which is a critical safety requirement in maintaining the integrity of smoke compartments within the facility.
Plan Of Correction
1. Facility maintenance staff fixed latch on doors to resident rooms 23B and 10B and ensured doors closed and latched on 4/30/2025. 2. Monthly door inspection form was created and provided to Plant Operations manager on 05/06/2025. 3. Facility maintenance staff will begin documenting monthly fire door inspections of all fire doors on both corridors by 5/23/2025. 4. Completion of inspections and corresponding documentation will be audited at the Building and Safety Meeting attended by The Plant Operations Manager, Director of Environmental Services, FCMC Safety Officer, Nursing Home Administrator and Chief Operations Officer for six months.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of one resident who was administered incorrect doses of insulin on multiple occasions. The facility's policy required that medications be administered as ordered by the physician, ensuring the right resident received the right medication at the right time. However, a review of the Medication Administration Record (MAR) for the resident revealed several instances where the insulin dosage administered did not match the physician's orders. Specifically, the resident was given higher doses of insulin than prescribed on several dates, and insulin was administered when it should have been withheld according to the sliding scale instructions. The resident in question was cognitively intact and required assistance for care needs, with a diagnosis of Type I diabetes, necessitating careful management of blood sugar levels through insulin administration. The physician's orders included a specific sliding scale for insulin administration before meals and at bedtime, with different dosages based on blood sugar readings. Despite these clear instructions, the facility's staff failed to adhere to the prescribed dosages, leading to significant medication errors. The Director of Nursing confirmed that the insulin was not administered as ordered by the physician on the specified dates.
Plan Of Correction
1. Facility did not identify any additional residents with dose administration errors. 2. On the spot education initiated on 4/18/2025 for Registered nurses and Licensed practical nurses that reviewed the format of insulin administration orders and the need to read entire order because administration doses can vary at different administration times. 3. Further investigation identified root cause of error as nurse clinical judgement to administer the AC (before meals) dosage because insulin was being administered with evening snack. All errors made by the same licensed practical nurse. 4. Individual education completed on proper usage of AC (before meals) and HS (at bedtime) terminology with employee who made the administration dose error on 4/28/2025. 5. Facility initiated additional on the spot education on 5/6/2025 to all registered nurses and licensed practical nurses reviewing the definition of HS and AC and proper use of terminology. Education will be completed by 5/27/2025. 6. Director of Nursing will complete weekly dose administration audits on insulin administration given by employee who made the administration error. Audits will be completed weekly for 4 consecutive weeks then monthly for 2 consecutive months. 7. Director of Nursing will complete random insulin dose administration audits monthly for 3 consecutive months. 8. Results of audits will be reported at the Quality Assurance and Performance Improvement meeting.
Expired Medical Supplies Found in Medication Rooms
Penalty
Summary
The facility failed to discard expired medical supplies in two medication rooms, Overly Meadows and Shimer Trails. During an observation in the Overly Meadows medication room, it was found that there were six 24 gauge angiocatheters that expired on November 30, 2024, one 18 gauge needle that expired on January 31, 2021, and a box of 25 vials of 20 cc normal saline solution that expired on November 1, 2023. A Licensed Practical Nurse confirmed that these items should not have been in circulation if they were expired. Similarly, in the Shimer Trails medication room, there were nine 24 gauge IV catheters that expired on April 30, 2023, two 20 gauge IV catheters that expired on August 31, 2023, and twenty-seven 22 gauge IV catheters, with 26 expiring on January 31, 2025, and one on December 31, 2024. Additionally, four 18 gauge needles expired on August 31, 2024, and one 10 cc syringe expired on September 30, 2024. Another Licensed Practical Nurse confirmed that these expired items should not have been in circulation. The Nursing Home Administrator also confirmed that these expired supplies should not have been in use.
Plan Of Correction
1. The facility ensured there are no additional medical supplies in circulation on both Shimer Trail and Overly Meadows that are expired. 2. The facility will update the process for monitoring medical supplies. Night shift licensed practical nurses will be responsible to monitor medical supply storage and ensure supplies are removed from circulation prior to their expiration date. 3. On the spot education of new process will be completed by all registered nurses and licensed practical nurses by 06/16/2025. 4. Semi-monthly audits will be completed by Director of Nursing or designee to ensure new process is being followed and that no expired medical supplies are in circulation. 5. Results of audits will be reported at the Quality Assurance and Performance Improvement meeting.
Failure to Provide Required Transfer Notices
Penalty
Summary
Fulton County Medical Center was found to be non-compliant with specific requirements of 42 CFR Part 483, Subpart B, concerning notice requirements before transfer or discharge of residents. The facility failed to provide written notice to the State Long-Term Care Ombudsman and the residents or their responsible parties regarding emergency transfers to the hospital for two residents. This deficiency was identified during a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey. The first case involved a resident who was cognitively intact and had his sister listed as the emergency contact. On two separate occasions, the resident was transferred to the hospital due to medical emergencies, including a severe skin rash and episodes of hematuria and rectal bleeding. However, there was no documented evidence that the required written notices were provided to the Ombudsman or the resident's sister regarding these transfers. The second case involved another cognitively intact resident who was transferred to the hospital after being found with abnormal vital signs and lab results indicating a potential infection. Similar to the first case, there was no documented evidence that the required written notices were provided to the Ombudsman or the resident's responsible party. The Director of Nursing confirmed the lack of documentation for both residents' transfers.
Plan Of Correction
1. Facility provided transfer and discharge notification report to the State Ombudsman office for the month of March on 4/19/2025. 2. Facility created a formal notification letter on 4/20/2025. Letter that will be updated, specific to each transfer and discharge and be provided to the resident/resident representative starting 4/21/2025. 3. On the spot education began on 4/21/25 for the Interdisciplinary Team and Registered Nurses which reviews Notice requirements 483.15(c)(3)-(6)(8) and new process of notification letter and reporting to ombudsmen. Education will be completed by 5/21/25. 4. Administrator or designee will complete monthly audits of written notification to resident/resident representative and ombudsman reporting. Audits will be completed over 3 consecutive months and findings will be reported at the Quality Assurance and Performance Improvement meeting.
Failure to Update Care Plan for Dialysis Treatment
Penalty
Summary
The facility failed to update the care plan for a resident who was undergoing dialysis treatment. The resident, who was cognitively intact and required assistance for daily care needs, had a hemodialysis catheter in place as per the care plan dated August 7, 2023. However, nursing notes indicated that the resident had a left upper arm fistula placed on November 6, 2023, and the hemodialysis catheter was removed on May 7, 2024. Despite these significant changes in the resident's dialysis treatment, the care plan was not revised to reflect the removal of the catheter and the use of the fistula. Interviews with the resident and the Director of Nursing confirmed that the care plan should have been updated to reflect these changes. The resident himself confirmed the removal of the catheter and the presence of the fistula during an interview on April 15, 2024. The Director of Nursing acknowledged that the care plan was not updated as required, which was a failure to comply with the facility's policy and regulatory requirements for care plan revisions.
Plan Of Correction
1. On April 15, 2025 resident 37 care plan was updated to reflect discharge of hemodialysis catheter. No other residents were identified as having this issue. 2. Facility updated change in condition checklist to include discharged orders. Updates to care plan will be verified at morning Interdisciplinary team meeting as change in condition checklist is completed. 3. Facility will complete on the spot education with registered nurses, licensed practical nurses and the interdisciplinary team regarding requirements for timing and revisions of care plan based on §483.21(b)(2)(i)-(iii) and need to update and reflect current care needs. Education will be completed by 5/29/2025. 4. Director of Nursing or designee will perform weekly audits that care plan updates have been made in relation to discharge orders. Audits will be performed weekly for 1 month then monthly for 2 consecutive months. 5. Results of audits will be reported at the Quality Assurance and Performance Improvement meeting.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents who received hospice services. The agreement between the facility and the hospice provider outlined the hospice's responsibility to provide necessary documentation, including the Hospice Benefit of Election form, plan of care, and other critical information. However, this information was not documented in the clinical records of the two residents reviewed. Resident 27, who had diagnoses including heart failure and adult failure to thrive, was admitted to the facility and received hospice care. Despite the hospice provider's care plan indicating scheduled visits, there was no documented evidence of the Hospice Benefit of Election form or communication from the hospice provider after a certain date. This lack of documentation indicates a failure in maintaining accurate and complete records as required by the agreement. Similarly, Resident 36, who had a history of cerebral vascular accident with hemiplegia and aphasia, was also receiving hospice care. The resident's clinical record lacked the Hospice Benefit of Election form, which was confirmed during an interview with the Nursing Home Administrator. The absence of this documentation in both residents' records highlights a deficiency in the facility's coordination and communication with the hospice provider.
Plan Of Correction
1. Facility ensured that Benefit of election from and required documents were filed into resident 27 and resident 36 clinical chart on 4/18/2025. Facility has no additional Hospice residents at this time. 2. Facility social worker has been identified as coordinator to ensure communication the plan is implemented and that appropriate documents are available in the physical chart for the interdisciplinary team with all future hospice admissions as of 4/25/25. 3. Facility and Hospice provider will implement a communication plan that ensures physical documents are available in the physical chart for interdisciplinary team review by 5/23/2025. 4. Facility will complete on the spot education regarding communication plan to their interdisciplinary team as well as Hospice Director of Business Development by 5/30/2025. 5. Administrator or designee will complete monthly audits of new hospice charts to ensure communication plan is in place and that required documentation is available to the interdisciplinary team in the chart. Audits will be conducted for 3 consecutive months and results will be reported at Quality Assurance and Performance Improvement Meeting.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for a resident. The resident, who was cognitively intact and required assistance for care needs, had a diagnosis of left arm hematoma and sepsis. Physician's orders required specific wound care procedures, including cleansing the left arm with normal saline and packing the wound with iodoform. During an observation, an LPN donned a gown and gloves, removed the resident's dressing, and cleansed the area. However, the LPN did not perform hand hygiene after removing her gloves and before donning new ones, which is a critical step in infection control. Additionally, the LPN failed to remove her gloves and perform hand hygiene before repositioning the resident's pillows, further compromising infection control protocols. The Director of Nursing confirmed that the LPN should have washed or sanitized her hands after removing gloves and before donning new ones, as well as before repositioning the resident's pillows. This oversight in following the facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing illness, led to the deficiency.
Plan Of Correction
1. Facility provided immediate education to employee who failed to ensure proper infection control practices during wound care. 2. Facility initiated on the spot education to all registered nurses and licensed practical nurses on 4/18/2025 regarding general hand hygiene practices and specific to wound care procedures. Education will be completed by 5/18/2025. 3. Hand hygiene competency, specific to wound care procedures, will be added annual education and competency requirements starting 6/1/2025. 4. Random wound care observation audits will be completed by Director of Nursing or designee once a week for 4 weeks, then monthly for 2 consecutive months. 5. Results of audits will be reported at the Quality Assurance and Performance Improvement meeting.
Failure to Maintain Safe Operating Condition of Laundry Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition in the laundry area, specifically regarding the automatic detergent dispensing system. Observations revealed that one of the washing machines had a malfunctioning automatic feeder, which was not dispensing detergent as required. As a result, Environmental Service Staff (ESS) 3 had to manually transfer detergent from a five-gallon bucket to the washing machine using a clear handled cup. This issue had persisted for approximately three months, and although it was reported to the supervisor, no effective action had been taken to resolve it. Interviews with the Nursing Home Administrator and Environmental Service Director indicated a lack of awareness and follow-up on the malfunctioning equipment. The Environmental Service Director was aware of the issue and had contacted the company for replacement parts but had not followed up further. The Nursing Home Administrator was unaware of the problem and confirmed that there were no work orders for repairs, acknowledging that the washing machine should be in functional order. This lack of communication and action contributed to the ongoing deficiency in maintaining safe operating conditions for essential equipment.
Plan Of Correction
1. On 4/17/2025, Facility Director of Environmental Services contacted the manufacturer to determine the delivery date of the part to repair the automated dispenser. The anticipated delivery date given was May 1. 2. On the spot education was completed on 4/18/2025 with laundry personnel. Additional education to general housekeepers was completed on 5/1/2025. Education included the manufacturer's instructions on manual application of detergent if the automated system is not functional. 3. The automatic dispenser part was repaired and is now functional as of 4/30/2025. 4. The facility completed on the spot education to all staff reviewing that work orders need to be entered when equipment needs repair. If staff do not have access to enter work orders, the Registered Nurse should be notified. Education will be completed by 6/16/2025. 5. The Administrator or designee will complete random audits weekly for 4 weeks and then monthly for 2 consecutive months to ensure work orders are put in for equipment that needs repair.
Neglect Leads to Resident's Dislocated Shoulder
Penalty
Summary
The facility failed to ensure that residents were free from neglect, resulting in a dislocated shoulder for one resident. The resident, who was cognitively impaired and dependent on staff for all daily care needs, exhibited increased behaviors and requested pain relief. Nursing notes indicated that the resident had multiple bruises on her upper arm, which were painful to touch, and the bruising and swelling worsened over time. An x-ray confirmed a dislocated left shoulder. The facility's investigation revealed that a nurse aide forcibly moved the resident's arm while providing care, causing the dislocation. A witness statement confirmed the forceful movement, and the resident immediately complained of pain and tingling in her fingers. A registered nurse assessed the resident but did not examine the upper arm or shoulder due to the resident's resistance. The Director of Nursing confirmed the nurse aide's actions led to the injury.
Plan Of Correction
1. Nurse Aid 2 was immediately suspended pending investigation of claims of abuse. After findings of abuse were substantiated, her employment at FCMC was terminated on 11/25/2024. 2. Facility completed on the spot education related to Residents' Right to be free from Abuse and Neglect F600 and Reporting Requirements F607, as well as FCMC policy on how to report. Education was completed on 11/26/2024. 3. Contracted Virtual In-Service training on F600 Freedom from abuse and neglect and misappropriation. Staff not able to attend in person were required to watch the recorded session and complete a post-test in HealthStream. Virtual Training was completed on 11/26/24. HealthStream Education was completed on 12/4/24. 4. Directed In-Service Training for all staff is contracted to be completed on Friday, 12/20/2024. Training will include F600 42 CFR. 6. Attendance to the Directed In-Service training will be monitored by the administrator, and compliance will be reported to the Quality Assurance and Performance Improvement committee by email.
Failure to Report Abuse Timely Resulting in Delayed Treatment
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of possible abuse, resulting in pain and delayed treatment for a resident with a dislocated shoulder. The facility's abuse policy required staff to report any suspicion of abuse immediately to their supervisor. However, a witness statement revealed that a nurse aide observed another aide forcefully move a resident's arm, causing a dislocated shoulder, but did not report the incident until questioned six days later. This delay in reporting led to a delay in care and treatment for the resident. The resident involved was cognitively impaired and dependent on staff for all daily care needs. Nursing notes indicated that the resident exhibited increased behaviors and requested pain relief. Subsequent notes documented bruising and pain in the resident's upper arm, leading to an x-ray that confirmed a dislocated shoulder. The facility's investigation determined that the forceful movement by the nurse aide caused the injury, and the failure to report the incident promptly resulted in a delay in addressing the resident's pain and injury.
Plan Of Correction
1. Nurse Aid 1 failed to report observed abuse in a timely manner and was suspended pending completion of investigation. Employee was terminated upon completion of investigation when determination was made that she reported the resident complaint of pain but not the witnessed abuse. 11/26/2024 2. Facility completed on the spot education related to Reporting Requirements F607 and FCMC policy on reporting suspected or witnessed abuse to supervisor immediately. Education completed on 11/26/2024. 3. Completed Virtual In-Service training on F607 Reporting Requirements. Staff not able to attend in person were required to watch the recorded session and complete a post test in HealthStream. Virtual Training completed 11/26/24. HealthStream Education completed 12/4/24. 4. Directed In-Service Training for all staff is contracted to be completed on Friday 12/20/24. Training will include F607 42 CFR §483.12(b)(1)-(5)(ii)(iii) Develop/Implement Abuse/Neglect Policies - timely reporting of abuse. The training will include: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/response. 5. Attendance to the Directed In service training on F607 will be monitored by the administrator and compliance will be reported to the Quality Assurance and Performance Improvement committee by email.
Incomplete Documentation and Assessment of Resident's Care
Penalty
Summary
The facility failed to ensure that a resident's clinical records were complete and accurately documented. A quarterly Minimum Data Set (MDS) assessment for a resident revealed cognitive impairment and dependency on staff for all daily care needs. An incident occurred where the resident was yelling and resisting care, and a nurse aide was observed forcing the resident's arm in a manner that resulted in a deformity and complaints of pain. Despite the resident's complaints, there was no documented evidence of a comprehensive assessment by a registered nurse on the days following the incident. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed the lack of documentation regarding the resident's assessment on the specified dates. The registered nurse admitted to only assessing the resident from the elbow down due to resistance, and the Director of Nursing acknowledged the absence of necessary documentation in the resident's clinical record. This lack of documentation and incomplete assessment contributed to the deficiency identified in the facility's handling of the resident's care.
Plan Of Correction
1. Documentation of the registered nurse pain assessment that was completed on 11/15/2024 was submitted as part of an investigation witness statement on 11/19/2024 by the assessing nurse. This document is filed in the resident's paper chart. 2. Individual counseling occurred with RN who completed the pain assessment and failed to document in electronic medical record on 11/27/2024. Oral discipline was issued due to failure to follow FCMC Pain Assessment and Management policy that states pain assessments must be documented in electronic medical record. 3. All Registered Nurse staff educated to the FCMC Pain Assessment and Management policy including documentation in electronic medical record and reporting new pain to the Inter Disciplinary Team at the morning clinical meeting. 4. Monitoring of documentation of pain assessments with reports of new pain will be completed on change in condition tracker at daily morning clinical meeting. Director of nursing will follow up individually with staff with appropriate discipline when documentation is not complete.
Failure to Store Food According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. The facility's policy, dated March 13, 2024, required that food be stored in clear plastic containers with lids, labeled with the name of the food, and dated with a prepared date and a use-by date. Observations in the walk-in freezer revealed opened and unlabeled bags of corn with peppers and onions, green beans, hamburger patties, and hash browns that were not in clear plastic containers. Additionally, the walk-in refrigerator contained an opened and unlabeled five-pound container of cottage cheese, a three-pound container of whipped cream cheese spread that was opened, undated, and had a best-by date of March 21, 2024, and a 64-ounce container of almond milk that was opened, unlabeled, and had a best-by date of April 15, 2024. The Dietary Manager confirmed that staff should be using a label maker to put a sticker on the food item when a new container is opened and that containers should be labeled with the date when opened.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for the use of anticoagulant medication for one resident. The facility's policy requires an individualized care plan to be developed by the interdisciplinary team within 21 days of admission, addressing various needs identified through resident involvement and assessments. However, for Resident 40, who had a diagnosis of pulmonary embolism requiring long-term use of anticoagulant medications, no care plan was created to address the use and risks associated with these medications. A quarterly Minimum Data Set (MDS) assessment revealed that Resident 40 was severely cognitively impaired and required assistance for daily care needs. Despite having a physician's order for the resident to receive 5 mg of Apixaban twice a day, there was no documented evidence of a care plan for the anticoagulant medication. The Director of Nursing confirmed that a care plan had not been created for this resident's use of anticoagulant medications.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for four residents were updated or revised to reflect their specific care needs. For Resident 25, the care plan was not revised to include interventions for her delusional thoughts, despite nursing notes documenting her concerns about imaginary people. The Director of Nursing confirmed that the care plan was not updated to address these behaviors. Resident 30's care plan was not updated to include the use of a reacher tool for fall prevention, even though an occupational therapy evaluation recommended its use after the resident fell and hit his head. The Director of Nursing confirmed that the care plan should have been updated to reflect this intervention. Resident 39's care plan was not updated to indicate the discontinuation of CPAP and the initiation of oxygen therapy at night and as needed during the day. Similarly, Resident 40's care plan was not updated to reflect her suicidal ideation and the use of behavioral health services, despite multiple nursing notes documenting her verbalizations of wanting to die. The Director of Nursing confirmed that these care plans should have been updated to reflect the residents' current needs.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine if a resident was safe to self-administer medications. The facility's policy required a physician's order and an evaluation to determine if a resident could self-administer medications. However, for Resident 28, who was cognitively intact but required extensive assistance and had hemiplegia, there was no documented evidence of such an evaluation or a physician's order for self-administration of medications. Despite this, a Licensed Practical Nurse (LPN) left a 1 gram tablet of Carafate on the resident's bedside table and left the room, which was against the facility's medication administration policy that required the nurse to stay with the resident until the medication was taken. Interviews with the LPN and the Assistant Director of Nursing confirmed that the LPN should not have left the medication with the resident and that no assessment had been completed to determine the resident's capability to self-administer medications. This incident was a clear violation of the facility's policies and the state regulation 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to ensure timely notification of the physician regarding a change in condition for one of the residents. Resident 25, who was cognitively intact and independent for care, had a care plan requiring physician notification for all medication refusals. Despite this, the resident's electronic medication administration record showed multiple instances of refused morning medications over three months, with no documented evidence that the physician was informed. The Director of Nursing confirmed the lack of notification documentation during an interview.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that appropriate treatment and services were provided to prevent the development of pressure ulcers for a resident. The resident, who had Parkinson's disease and dementia, was admitted with a small red mark on the right posterior thigh from his brief. Despite this, there was no documented evidence that the resident's brief was evaluated or that preventive interventions were started when the red mark was identified. This red mark progressed to a blister over the following days. On February 24, 2024, a nursing note revealed that the resident had developed a 30 cm by 7 cm water blister on the left upper/inner thigh, which was later documented as a serum-filled blister. The interdisciplinary team identified the root cause as related to the brief placement and recommended evaluating the brief's placement and applying skin prep to the blister. However, the Director of Nursing confirmed that there was no documented evidence of any preventive measures being taken when the initial red mark was identified, leading to the development of the blister.
Failure to Use Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure that each resident received appropriate assistance devices to prevent accidents. Specifically, two residents were observed being transported in wheelchairs without footrests, which could lead to their feet dragging and potential injury. Resident 40, who has Alzheimer's disease and is severely cognitively impaired, was transported without footrests by an LPN who was unsure if they were needed. Similarly, Resident 42, who is cognitively intact but requires assistance for daily care needs, was transported without footrests by a Nurse Aide. Both staff members confirmed that footrests should have been used during transport. The facility's policy on wheelchairs, dated March 13, 2024, mandates that all wheelchairs used for transport must be equipped with leg rests. Interviews with the Director of Nursing and the involved staff confirmed that the policy was not followed in these instances. The deficiency was identified during a review of policies, clinical records, observations, and staff interviews, highlighting a failure to adhere to established safety protocols designed to prevent accidents.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for two of five nurse aides reviewed. Nurse Aide 6, hired on April 13, 2021, did not have a documented performance evaluation for April 2023, although an evaluation was completed on December 15, 2023. Similarly, Nurse Aide 7, hired on June 6, 2022, did not have a documented performance evaluation for June 2023, despite having an evaluation on December 28, 2023. The Nursing Home Administrator confirmed the absence of the required annual performance evaluations during an interview on May 1, 2024.
QAPI Committee Fails to Maintain Compliance with Quality Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and maintain compliance with quality deficiencies identified in previous surveys. Specifically, the deficiencies related to the notification of changes in resident conditions and annual nurse aide performance evaluations were not adequately addressed. The facility had previously developed plans of correction that included quality assurance systems to ensure compliance with nursing home regulations. However, the current survey revealed repeated deficiencies in these areas, indicating that the QAPI committee did not effectively implement or sustain the corrective measures outlined in the plans of correction. The deficiencies regarding the notification of changes in resident conditions were cited under F580, and the deficiencies related to annual nurse aide performance evaluations were cited under F730. Despite the facility's plans to complete audits and report the results to the QAPI committee for review, the current survey found that these measures were not maintained. This failure to sustain compliance with the cited regulations highlights ongoing issues in the facility's quality assurance processes and the effectiveness of its QAPI committee in addressing and rectifying recurring deficiencies.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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